VA Heartland Network (VISN 15)

Issue: VA employee in Cardiology sent a CD-ROM containing results from a heart catheterization for one patient to the Denver VA Medical Center. The CD-ROM was sent Thursday utilizing UPS with the overnight option. The VA employee did receive a UPS…

Outcome: NA

Issue: An appointment letter for one Veteran got mixed up (was mis-mailed) to another Veteran. Recipient of the wrong information returned the letter to Social-Work(SW) Service. The SW immediately routed the information securely to the Privacy Office with the specifics. Update:…

Outcome: Notification made to Department supervisor as well as staff who sent letter for quality improvement; action plan will be to double check all letters for accuracy prior to delivery. (Staffer immediately made corrective action in order for non-recipient to receive…

Issue: A Primary Care Nurse Practitioner provided the lab results of Veteran B to Veteran A during his clinic visit. Veteran A telephoned and was instructed by clinic staff to destroy the wrong lab document. Veteran A states he has shredded…

Outcome: Education was provided. Notification letter has been mailed.…

Issue: A Patient and his wife stopped by the ISO's office on April 1, 2013 to request a listing of staff that has accessed his record. The patients wife returned to the ISO office on April 11, 2013. She stated that…

Outcome: This individual received a written counseling letter and will be meeting with the Privacy Officer for education. Privacy re-training provided one-on-one with individual: provided references; statutes and discussion in order to bring forth better understanding of confidentiality and the importance…

Issue: Veteran A received information in the mail and subsequently realized the envelope also contained records belonging to five other individuals. Veteran A subsequently returned the records (that did not belong to him) to the clerk at the Community Based Outpatient…

Outcome: NA

Issue: Means Test paperwork of Veteran A was mis-mailed to Veteran B and Veteran B's Means Test paperwork was mis-mailed to Veteran A Update: 03/12/13:Both Veterans will be sent letters offering credit protection services.…

Outcome: Responsible employee counseled by supervisor and re-educated on responsibility of ensuring proper security when mailing sensitive information. Recommend incident be closed.…

Issue: A Veteran employee forwarded an e-mail from her supervisor to the Privacy Officer (PO). Her supervisor told her that "You were checked in as a Veteran to see your provider at 10:00 AM so your leave started at 10:)) AM"…

Outcome: Education was given to employee by supervisor.

Issue: On 02/28/13, Veteran A returned Veteran Bs medication reconciliation sheet to the Administrative Officer of the Day (AOD). Veteran A inadvertently received the reconciliation sheet on 01/17/13 (after discovering it wasnt his since had no need for it). This was…

Outcome: Supervisor notified, privacy re-education provided to new clerk in check-in area of importance in safeguarding and double-checking information prior to...Notification letter mailed. Redacted copy attached; Please close ticket; thanks.…

Issue: A report was received that an employee was overheard talking to her daughter about a Veteran's medical appointment on 02/27/13. On 02/28/13, the employee allegedly was overheard talking with the Veteran, reassuring him that his medical information would remain confidential.…

Outcome: The following measures have already been taken to lessen the likelihood of future incidents of this nature: 1) To further protect your medical information, including your contact information, your records have been marked with a higher level of security. 2)…

Issue: A box of Concurrent Monitor Worksheets for High Acuity patients was found in an unsecured area. The room was open without anyone in the room. The Privacy Officer (PO) is unable to determine how long the box was in the…

Outcome: Training is being provided to all staff regarding the safekeeping of records and the importance of records management.